1861942948 NPI number — PERRY MEMORIAL HOSPITAL AUTHORITY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861942948 NPI number — PERRY MEMORIAL HOSPITAL AUTHORITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERRY MEMORIAL HOSPITAL AUTHORITY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMMUNITY MEDICAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861942948
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1318 ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PERRY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73077-5034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 N 14TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERRY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73077-5021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-336-2176
Provider Business Practice Location Address Fax Number:
580-336-3178
Provider Enumeration Date:
10/12/2016

Additional Information

Authorized Official

Authorized Official Last Name:
FULLER
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHAIRMAN OF THE BOARD
Authorized Official Telephone Number:
580-336-2176

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2268 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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